The synergies of responses to communicable and noncommunicable diseases has risen in importance as countries search for the most efficient and effective ways to meet global health goals. National HIV responses must address the rising prevalence of noncommunicable diseases globally and take into account the increased understanding of the importance of social determinants of health and of addressing mental health issues.
The International AIDS Society–Lancet Commission explored how advancing global health and
strengthening the HIV response can be achieved in unison. The Commission’s 2018 report called for HIV services to be co-located with broader health services where possible, with the aim of improving both HIV-related and non-HIV-specific health outcomes (1).
The provision of services for HIV, tuberculosis, viral hepatitis, sexually transmitted infections (STIs) and human papillomavirus (HPV) have clear synergies, as these epidemics have similar modes of transmission and affect similar hard-to-reach populations.
The integration of HIV services into sexual and
reproductive health care, family planning, maternal and child health care, and food and nutritional support has comparable advantages.
However, the International AIDS Society–Lancet Commission warned against wholesale relinquishment of a focused approach to HIV (1). It found that the exceptional nature of the HIV response has driven its ability to mobilize financial, technical and human resources, unite diverse stakeholders, focus global attention on concrete results, stimulate scientific innovation and engage communities. The Commission stressed that the greater integration of HIV and global health “must preserve and build on key attributes of the HIV response, including participatory community and civil society engagement and an ironclad commitment to human rights, gender equality, and equitable access to health and social justice” (1).
Ultimately, people are at the centre of efforts to end the spread of disease and uphold the right to health
—and a people-centred approach is needed to achieve global health goals.
Integration of quality HIV and other related services can improve the health and well-being of people in need of these services and improve the efficiency and
effectiveness of efforts to meet global health goals.
Scale-up of HIV treatment and improvements in the delivery of HIV and tuberculosis services have greatly reduced tuberculosis-related deaths among people living with HIV.
National plans for hepatitis prevention and treatment should include focused efforts to reach two populations at high risk of infection:
prisoners and people who inject drugs.
Efforts to end the AIDS epidemic and achieve all of the health commitments within the Sustainable Development Goals are being enabled by the movement for universal health coverage.
AT A GLANCE
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INTEGRATED, PEOPLE-CENTRED SERVICES PART 1
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PART TITLEFIGURE 8.1 Number of tuberculosis-related deaths among people living with HIV, global, 2000–2017
FIGURE 8.3A Distribution of tuberculosis-related deaths among people living with HIV, global, 2017
Source: Global tuberculosis report. Geneva: World Health Organization; 2018.
Source: Global tuberculosis report. Geneva: World Health Organization; 2018.
0
2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020
Number of tuberculosis-related deaths
Tuberculosis–related deaths Target Tuberculosis-related deaths Target
19%
Mozambique United Republic of Tanzania
Kenya Uganda
Zambia India
Indonesia Angola
Rest of the world
South Africa Nigeria Mozambique United Republic of Tanzania Kenya Uganda Zambia India Indonesia Angola Rest of the world
Reductions in tuberculosis-related deaths among people living with HIV
A person living with HIV is approximately 16 to 27 times more likely to develop active tuberculosis than an HIV-negative person (2). Scale-up of antiretroviral therapy and improvements in the delivery of HIV and tuberculosis services has greatly reduced tuberculosis-related deaths among people living with HIV (Figure 8.1). However, tuberculosis remains the single largest cause of premature death among people living with HIV globally.
The World Health Organization (WHO) has strongly recommended treatment for latent tuberculosis infection in people living with HIV. Among the 30 countries with a high HIV and tuberculosis burden, 21 reported having policies in place on isoniazid
preventive therapy or latent tuberculosis infection prophylaxis for people living with HIV. Coverage of preventative treatment among people newly enrolled in HIV care in 2017 remained low among many of the 30 countries with a high burden of HIV and tuberculosis, ranging from 1% in Eswatini to 53%
in South Africa (3).
Provision of preventive treatment to people living with HIV appears to have increased in 2018 (Figure 8.2), but this rise may be partially due to changes in reporting. Until 2016, countries reported the number of people living with HIV newly enrolled in HIV care who received preventive treatment for tuberculosis.
As of 2017, however, countries could report the number of people living with HIV both newly and currently enrolled in HIV care who received preventive treatment for tuberculosis.
TITLE OF THE ARTICLE
0
2000 2002 2004 2006 2008 2010 2012 2014 2016 2018
Number of people
Global
Sub-Saharan Africa Rest of the world
FIGURE 8.2 People living with HIV who received preventive treatment for tuberculosis, 2000–2018
2018
Note: Data for 2018 are preliminary. Until 2016, countries reported the number of people living with HIV newly enrolled in HIV care who received preventive treatment for tuberculosis. As of 2017, countries could report the number of people living with HIV both newly and/or currently enrolled in HIV care who received preventive treatment for tuberculosis.
Source: 2019 Global AIDS Monitoring; Global tuberculosis report.
Geneva: World Health Organization; 2018.
Global Sub-Saharan Africa Rest of the world
163
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1 FIGURE 8.3 National plans referencing interventions for hepatitis in people who inject drugs, 2019
Source: Access to hepatitis C testing and treatment for people who inject drugs and people in prisons—a global perspective.
Geneva: World Health Organization; 2019 (https://www.who.int/hepatitis/publications/idu-prison-access-hepatitis-c/en/).
Hepatitis plan does not reference interventions for people who inject drugs Hepatitis plan not accessed Hepatitis plan references interventions for people who inject drugs
2
TITLE OF THE ARTICLE
FIGURE 8.4 National plans referencing interventions for hepatitis in people in prisons, 2019
Source: Access to hepatitis C testing and treatment for people who inject drugs and people in prisons—a global perspective.
Geneva: World Health Organization; 2019 (https://www.who.int/hepatitis/publications/idu-prison-access-hepatitis-c/en/).
Hepatitis plan does not reference interventions for people in prisons Hepatitis plan not accessed Hepatitis plan references interventions for people in prisons
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Prisoners and people who inject drugs key to reaching targets on viral hepatitis and HIV Viral hepatitis is easily spread through the sharing of non-sterile drug preparation and injecting equipment.
As a result, coinfection of viral hepatitis and HIV is common when people who inject drugs do not have access to needle–syringe programmes and other harm reduction measures. Almost one quarter of new hepatitis C infections are attributable to injecting drug use, and more than half of people who inject drugs have chronic hepatitis C infection (4, 5). An estimated 7% of people living with HIV who inject drugs have hepatitis B (4). The prison populations of most countries have higher hepatitis B and C prevalence than the general population (4).
Strong progress has been made in delivering prevention interventions (such as the hepatitis B vaccine) together with early but expanding testing and treatment access for both hepatitis B and C (6). Direct-acting antiviral medicines—only available since 2013 and with cure rates of greater than 90% and few side-effects—have revolutionized the treatment and cure of hepatitis C infection (6).
The number of countries with national hepatitis plans and strategies has increased from 12 in 2012 to 124 in 2019. However, many of these plans do not reference people who inject drugs and prisoners (Figures 8.3 and 8.4). Efforts to reach universal access to testing, hepatitis B treatment and the hepatitis C cure must reach these key populations in order to achieve global targets for reducing mortality from viral hepatitis (7).
1 The 35 Fast-Track countries together account for more than 90% of people acquiring HIV infection and 90% of people dying from AIDS-related illness worldwide.
Linkages and integration of HIV and cervical cancer prevention, screening and treatment Cervical cancer is the fourth most common cancer among women globally, with an estimated 570 000 new cases and 311 000 deaths worldwide in 2018 (8).
Women living with HIV face an up to fivefold greater risk of invasive cervical cancer than women who are not infected with HIV (9). This risk is linked to HPV, a common but preventable infection that women with compromised immune systems struggle to clear.
HPV immunization programmes for adolescent girls are a key strategy to preventing cervical cancer, and all women living with HIV should be screened for cervical cancer. Women found to have precancerous and cancerous lesions need to be treated for early or advanced stages of cervical cancer Linking and integrating cervical cancer services and HIV services is cost-effective and can be done at scale. Among the 35 Fast-Track countries in the UNAIDS 2016–2021 Strategy, 17 reported in 2019 that cervical cancer screening and treatment for women living with HIV is recommended in the national strategic plan governing the AIDS response.1 Twenty-one reported that cervical cancer screening and treatment for women living with HIV is recommended in national HIV treatment guidelines (Table 8.1). However, just four countries confirmed that cervical cancer screening is integrated with HIV services in all health facilities, and another 12 reported that these services are integrated in some health facilities.